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' SAN JOAQUIN COUNTY ' - <br /> NOTIr% �,HTION OF HAZARDOUS WASTE Di. ,:HARGE <br /> HEALTH & SAFETY CODE 25180. 7 <br /> 03 D <br /> A. EMERGENCY LEVEL: II III PHS EH LOG # <br /> (Pin le One) <br /> Be SOURCE, O I FORMATION <br /> Name : �-� Phone: ( 7 2© 20 <br /> Company: �A� ZaU 7rZCAPS <br /> Address : <�9-7P / m5Lwo::r- 2 <br /> Designated Employee Name : Phone: L� <br /> Reporting Agency Name: <br /> Address : <br /> C. LOCATION AND DATE, OF DIS GE / <br /> Location: S <br /> (Best Physical scri tion) it} or County) Circle One <br /> Date of Discharge : — <br /> Date Notified: .Sa axe12, Time' o+•— <br /> D. RESPONSIBLE PERSON`BUSINES,� <br /> Name of Business : ( <br /> Contact Person: Telephone : f ) �,39 FLOO <br /> Physical Address : aD2o D L� � � ��a X53 <br /> Mailing Address : ,4� _ <br /> E. DESCRIPTION <br /> Type of Discharge : �"� <br /> Volume : <br /> Chemicals : aae - TPS G <br /> Circumstance <br /> F. ACTION TAKEN./ * <br /> Q.• GJt20 £ ti 4 S a aace <br /> SITE DISPOSITION / • S ? - <br /> ) . 2 . <br /> C � m <br /> EH 22 013 (Re <br /> v.4/91 ) <br />